Direct Deposit Authorization Form - Modern Business Associates
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1Ver 2.0 CS0808
Template created by Modern Business Associates
1-888-622-6460
Modern Business Associates provides a one-stop answer to all of your business human resources-related needs.
Modern Business Associates
Dept. / Division: ___________
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IMPORTANT: All information is required for MBA to process direct deposit.
The following amounts will be deducted from your paycheck each pay period:
Your name must appear on the account designated below and the attached voided check.
Description
Amount or Net
Direct
*Financial Institution Name:_______________________________
Deposit Account No.: _________________________________________
#1
Routing Number: _______________________________________
Net Pay
Type of Account: Checking
Savings
Investment Account
Direct
*Financial Institution Name:_______________________________
Deposit Account No.: _________________________________________
#2
Routing Number: _______________________________________
$_________
Type of Account: Checking
Savings
Investment Account
Direct
*Financial Institution Name:_______________________________
Deposit Account No.: _________________________________________
#3
Routing Number: _______________________________________
$_________
Type of Account: Checking
Savings
Investment Account
*Financial institutions include banks, savings and loans, credit unions, and investment accounts.
I hereby authorize Modern Business Associates to deduct from my paycheck the noted amounts
EACH PAY PERIOD and to initiate adjustments if necessary for any entries made in error. Any
changes must be in writing on the Direct Deposit Authorization form. I understand that it may
take up to 30 days before my deposit request is initiated.
Signature: __________________________________ Date: _____________
Social Security Number ____________-_________-____________
Please attach one of the following for each direct deposit:
-
a voided check or copy of a check
-
a copy of the Financial Institution Identification Card
(for savings accounts)
Note: Incomplete or unacceptable information will delay the start of your direct deposit(s).
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